Authorization Agreement For Automated Bank Draft (Ach Debits) Form

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Holy Family Catholic Church
Post Office Box 290, 474 N Jefferson Avenue
Port Allen, Louisiana 70767
Phone: (225) 383-1838
Fax: (225) 383-1839
Authorization Agreement for Automated Bank Draft (ACH Debits)
Automated Payment Authorization:
I (we) hereby authorize Holy Family Church to initiate debit entries to my (our) account designated below at the depository
financial institution named below, hereinafter called DEPOSITORY, and to debit same account. I authorize credit entries,
if necessary, for any debit entries that are determined to be in error. I acknowledge that the origination of ACH
transactions to my account must comply with the provisions of U.S. law.
This authorization is to remain in full force and effect until Holy Family Church (via mail at the address above) and
DEPOSITORY have received written notification from me (or either of us) of its termination that is to be received at least
three (3) days prior to the proposed effective date of the termination of the authorization to afford Holy Family Church and
DEPOSITORY a reasonable opportunity to act on it.
Deposit Account Information:
Bank Name: ___________________________ Branch: _______________________ Telephone: ______________
Address: _________________________________________ City/State/Zip: ________________________________
Routing Number: __________________________________
(9 digits - located bottom left corner of checks)
Account Number: __________________________________
Account Type:
Checking
Savings
Account Holder Information:
Account Holder’s Name: _____________________________________________
Indicate below the amount you wish to deduct in the appropriate category:
Stewardship Offering: General Collection
$ __________________ per month on the 10th of the month.
Jubilee Campaign / Building Maintenance Fund $ __________________ per month on the 10th of the month.
Signature: ________________________________________________________
Date: _______________________
Attach a voided check here.
Place this form in a sealed envelope and return to Holy Family Church
via the Sunday collection at Mass or mail to our office at the address listed above.

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